The money for Zanmi Lasante was funneled through a small public charity that Farmer had founded—Partners In Health, with headquarters in Boston. The bills were small by American standards. Farmer and his staff of community health workers treated most tuberculosis patients in their huts and spent between $150 and $200 to cure an uncomplicated case. The same cure in the United States, where most TB patients were hospitalized, usually cost between $15,000 and $20,000.
My local hospital in Massachusetts was treating about 175,000 patients a year and had an annual operating budget of $60 million. In 1999 Zanmi Lasante had treated roughly the same number of people, at the medical complex and out in the communities, and had spent about $1.5 million, half of that in the form of donated drugs. Some of the cash came from grants but most of it from private donations, the largest from a Boston developer named Tom White, who had given millions over the years. Farmer contributed, too, though he didn’t know exactly how much.
I became aware of the logistical facts of Farmer’s life only gradually, so they didn’t seem completely unusual until I totaled them up. In 1993 the MacArthur Foundation had given him one of its so-called genius grants—in his case some $220,000. He’d donated the entire sum to Partners In Health, to create a research branch for the organization—the Institute for Health and Social Justice, he called it. He made about $125,000 a year from Harvard and the Brigham, but he never saw his paychecks or the honoraria or royalties, both fairly small sums, that he received for his lectures and writings. The bookkeeper at PIH headquarters cashed the checks, paid his bills—and his mother’s mortgage—and put whatever was left in the treasury. One day in 1999, Farmer tried to use his credit card and was told he’d reached his limit, so he called the bookkeeper. She told him, “Honey, you are the hardest-workin’ broke man I know.”
Back when he was a bachelor, he’d stayed in the basement of Partners In Health headquarters during his sojourns in Boston. Four years ago he’d married a Haitian woman, Didi Bertrand. He saw no reason to change their Boston living quarters, but when their daughter was born, in 1998, his wife insisted it was time to move. Now they had an apartment in Eliot House at Harvard, which they used when in Boston. But they weren’t often there. These days, Didi and their two-year-old spent the academic year in Paris, where Didi was finishing her own studies in anthropology. Several friends had told Farmer he should spend more time with them. “But I don’t have any patients in Paris,” he’d say. It was obvious that he missed his family. When I was with him in Haiti, he called them at least once a day, from the room with the satellite phone. In theory, he spent four months in Boston and the rest of the year in Cange. In fact, those periods were all chopped up, by trips to places where he did have patients. Years ago he’d gotten a letter from American Airlines welcoming him to their million-mile club. He’d traveled at least two million miles since.
He had a small house in Cange, the closest thing in his life to a home, perched on a cliff across the road from the medical complex. It was a modified ti kay, a replica of the better sort of peasant house, with a metal roof and concrete floors and exceptional in that it had a bathroom, though without hot water. Many times when I looked inside his house, his bed appeared unused. He told me he slept about four hours a night but a few days later confessed, “I can’t sleep. There’s always somebody not getting treatment. I can’t stand that.”
Little sleep, no investment portfolio, no family around, no hot water. On an evening a few days after arriving in Cange, I wondered aloud what compensation he got for these various hardships. He told me, “If you’re making sacrifices, unless you’re automatically following some rule, it stands to reason that you’re trying to lessen some psychic discomfort. So, for example, if I took steps to be a doctor for those who don’t have medical care, it could be regarded as a sacrifice, but it could also be regarded as a way to deal with ambivalence.” He went on, and his voice changed a little. He didn’t bristle, but his tone had an edge: “I feel ambivalent about selling my services in a world where some can’t buy them. You can feel ambivalent about that, because you should feel ambivalent. Comma.”
This was for me one of the first of many encounters with Farmer’s use of the word comma, placed at the end of a sentence. It stood for the word that would follow the comma, which was asshole. I understood he wasn’t calling me one—he would never do that; he was almost invariably courteous. Comma was always directed at third parties, at those who felt comfortable with the current distribution of money and medicine in the world. And the implication, of course, was that you weren’t one of those. Were you?
In the mornings, I followed Farmer from the courtyard, to e-mail, and then to his office—on the ground floor of the newest building, the Thomas J. White Tuberculosis Center. Diplomas hung on the wall, together with a photograph of Haiti’s first elected president, Jean-Bertrand Aristide—Farmer’s friend of many years—posing with a boy whom Farmer had cured of TB. There was an examining table, an X-ray viewer, a desk, and a new office chair that the staff had bought him for Christmas. It still had some tinsel on it.
Farmer sits down at his desk. “Now the objective is?” He looks at me. I shrug. He says, “To stay put. Because people are lurking outside. Lurkaceous behavior.”
A crowd of perhaps thirty—on occasion, I counted forty—waits in the hall, some sitting on benches, some milling around. A nurse in white uniform enters, saying to Farmer, indignantly, “I always say patients must sit down, and they don’t listen to me.”
Farmer smiles at her, making the Haitian hand slap, the back of one hand into the palm of the other. “It’s a cross we must carry,” he says. The nurse stalks out. He looks over at me. “You can’t sympathize with the staff too much, or you risk not sympathizing with the patients.”
They are indeed the poor and the maimed and the halt and the blind. An elderly man in treatment for pulmonary TB who makes me think of Ray Charles. (He’s blind but wears glasses. He had said he wanted glasses, so Farmer had found him a pair.) A younger man whom Farmer refers to as Lazarus, who arrived some months ago on a bed frame carried by relatives, wasted by AIDS and TB to about 90 pounds, now weighing in at about 150, cured of TB and his AIDS arrested thanks to medications. A healthy-looking young woman whose father, only a month ago, was saving up for her coffin.
And, on the other hand, a lovely-looking young woman being treated for drug-resistant TB, now in the midst of a sickle-cell crisis and moaning in pain. “Okay, doudou. Okay, cherie,” Farmer coos. He orders morphine.
A man with gastritis in late middle age. In Haiti, Farmer told me, that could mean thirty years old, since 25 percent of Haitians die before they reach forty. “It’s because there’s a near famine here,” says Farmer, examining him. “The man is muscular. Perhaps in his declining years he can’t scrap for food as well, or maybe there’s someone he’s trying to feed.” He orders nutritional supplements.
A sixteen-year-old boy too weak to walk, who weighs only sixty pounds. Farmer diagnoses an ulcer. “His body’s gotten used to starvation. We’re gonna buff him up.” Farmer hefts a can of the dietary supplement Ensure. “This is good stuff. We’ll give him three cans a day. So we’ll give him a couple hundred dollars of Ensure, and I’ll take great pleasure in violating the principle of cost-efficacy.”
A very small, elderly-looking woman, her body bent at the waist, at a right angle. Long before Farmer met her, tuberculosis of the spine had devoured pieces of her backbone—a case of Pott’s disease, easily cured but it had gone untreated and was “burnt out.” There’s nothing to be done for it now. She’s come for money and food and company. Farmer stands when she enters, greeting her as mami mwen, “my mother.” He bends down, practically kneeling, and she kisses him on one cheek, then the other, and says, “A son always cares for his mother.” Farmer gets her a chair, and she holds on to it, still standing, resting her chin on the seat, and watches as he ministers to the next several patients.
As at the Brigham, he seems bound to get as c
lose to them as possible. He has them sit in a chair right next to his, so that, I figure, he can get his thin, white, long-fingered hands on them. He calls the older women “Mother,” the older men “Father.” Many bring him presents. Milk in a green bottle with a corncob stopper. “Oh, cheri! Mesi anpil, anpil!”—“Thank you, thank you!” Farmer says. He smiles and, staring at the bottle on his desk, says in English, “Unpasteurized cow’s milk in a dirty bottle. I can’t wait to drink it.” He turns to me. “It’s so awful you might as well be cheerful.”
I look up. A very pregnant woman is forcing her way past the nurse and in through his office door. She’s infected with HIV and is here to receive isoniazid prophylaxsis, having also been exposed to TB. She also needs money for food; her husband has died. She lifts her voice high and cries cheerily, “You guys are all my husbands!” A young man enters next. “Doktè Paul? I came here and was sick. Now I’m much better. So I would like a picture taken.”
On the wall beside his desk, Farmer has taped up three sheets of yellow legal paper, on every line a task to be completed, and beside each of those a hand-drawn box, in Creole a bwat. I’ve noticed that if he completes a chore that he forgot to put on the list, he writes down the chore, makes a bwat beside it, then puts a check in the box. This seems to give him an inordinate pleasure, and I must admit that I feel some myself, completely unjustified, when he says, “We’re getting a lot done.”
The list on the wall contains about sixty imperatives—to assemble the slides for upcoming speeches, to get Lazarus a Bible and a pair of nail clippers, to give another patient the wristwatch he bought for him in the Miami airport, to obtain sputum samples from some of the patients with drug-resistant TB and take them to Boston for testing. The list seems to speak of what, in Boston, might be called an interesting practice. Certainly it is varied. One item reads, “Sorcery consult.”
In one of his books, Farmer had written that there was a distinction, in the Haitian countryside, between belief in sorcery and “the theories and practices called voodoo.” That is, not every peasant practiced the indigenous religion called Voodoo, but virtually everyone, including Catholics and Protestants and Voodooists, believed in the reality of maji, of sorcery. For many people around Cange, magic spells sent by enemies were the deep cause of many illnesses. And many people around Cange believed that Farmer, like all good Voodoo priests, knew how to contend with maji.
One local peasant told me, speaking of Farmer, “God gives everyone a gift and his gift is healing.” Once at a public ceremony, a former patient of his stood up and declared, “I believe he is a god.” It was also said around Cange, usually in whispers, “Doktè Paul works with both hands”—that is, both with science and with the magic necessary to remove ensorcellments. Most of the encomiums seemed to embarrass and amuse Farmer. But this last, he’s explained, has a painful side. “Haitians believe in sorcery because their culture has evolved in the absence of effective medicine. So of course they believe in sorcery, in sicknesses that someone has sent to them. Why else would someone fall into a coma? And when someone is very sick and people are used to seeing them die with the same symptoms and you give them meds and they rapidly recover, people think. And then they start talking.” In his experience, most Haitians eagerly embrace effective medicine. He has dozens of Voodoo priests among his patients, some of them serving as virtual community health workers, bringing him ill parishioners.
Sorcery is, at bottom, the Haitians’ way of explaining suffering, but the allegations themselves can cause suffering. Now an elderly woman enters Farmer’s office. She’s the subject of the sorcery consult. The other day in the courtyard Farmer saw her son moping around and asked him what was wrong. “My mother hates me,” he said. In fact, the mother believes her son “sent” the sickness that killed another son. As she sits down beside Farmer and he begins telling her not that sorcery doesn’t exist but that he knows sorcery wasn’t involved in this instance, she lifts her chin and averts her face. Gradually, she softens. But it will probably take months to reconcile her fully with her surviving son. When she leaves, Farmer says he feels “eighty-six percent amused.” And, I suppose this means, 14 percent sad.
The woman had insisted that her son had “sold” his brother, using the Creole word once applied to slaves. (Haitian beliefs in sorcery were perhaps in part inspired by the slave masters’ own fears, born of guilt. “A great many beliefs and practices in Haitian magic originate from Normandy, Berry, Picardy or ancient Limousin,” writes the anthropologist Alfred Métraux.) Moreover, accusations like the woman’s always seem to spring from the jealousies that great scarcity inspires. The accused son lives in a better ti kay than his mother. In effect, she was saying this son didn’t care about his mother, so he must have been the one who sent sorcery to kill his brother. These kinds of allegations, accusations that arise out of economic inequalities, are common, Farmer says. They can tear families and friends apart. “When I realized that, I thought, Oh, man! It’s not enough that the Haitians get destroyed by everything else, but they also have an exquisite openness to being injured by words.”
After a few days in Cange with Farmer, I came to expect such interpretive discourses. Farmer called them “narrating Haiti.” I don’t want to exaggerate this tendency of his. He was capable of maintaining companionable silences, indeed, often seemed to prefer them to talk, and he made light conversation at least as often as he proselytized. Besides, I was trying to get the hang of his cosmology, so I egged him on, sometimes even badgered him into narrating Haiti. When he got going, though, everything around us became the occasion for drawing a moral about the suffering of the Haitian poor, which often also served as a lesson about the suffering of the world’s poor. Sometimes he’d pause to ask for a reaction: “You feelin’ me?”
And for me the problem often was that I couldn’t muster a sufficient response internally. I’d feel sorry that so many Haitian children still died of measles—though not in Zanmi Lasante’s catchment area—but I’d also feel that I could never be sorry enough to satisfy him. I’d end up annoyed at Farmer for a time, in the way one gets annoyed at others when one has done them a disservice.
Days and nights ran together. Farmer liked to tell his Harvard students that to be a good clinician you must never let a patient know that you have problems too, or that you’re in a hurry. “And the rewards are so great for just those simple things!” Of course, this meant that some patients waited most of a day to see him and that he rarely left his office before dark.
Through the louvered windows high on the wall behind his desk, I see stars shivering in the warm night. A sad-faced young man takes his seat beside Farmer and stares down at his own feet, shod in ragged running shoes, splitting at the heels. His name is Ti Ofa. He has AIDS. When he’s on duty at the Brigham, Farmer runs the hospital’s AIDS service, and he’s handled Ti Ofa’s case as he would have in Boston, treating various opportunistic infections with antibacterials, until the infections become chronic. Zanmi Lasante doesn’t have the wherewithal to measure viral loads and CD4 counts, but from long experience Farmer knows the virus is about to begin its endgame with Ti Ofa, its overwhelming stage. Ti Ofa says, “I feel ashamed.”
“Anybody can catch this. I told you that already,” Farmer says. He opens a drawer in his desk and takes out a large plastic bottle. It contains indinavir, one of the new protease inhibitors used for treating AIDS.
No one else, not at this time, is treating impoverished Haitians with the new antiretroviral drugs. Indeed, almost no one in any poor country is treating poor people who have the disease. Even some of Farmer’s friends in the Haitian medical establishment have told him he’s crazy to take on AIDS this way in Cange, and certainly many experts in international health would agree. Leaving aside all other objections, the new AIDS drugs could cost Zanmi Lasante about five thousand dollars a year per patient. Nonetheless, Farmer had started some patients on triple therapy. A few months ago, he gave a speech to a group in Massachusetts called Cambridge
Cares About AIDS. “Cambridge cares about AIDS,” he told them. “But not nearly enough.” He wondered if he’d gone too far, but afterward, at his suggestion, health workers in the audience and people who themselves had AIDS collected a bunch of unused drugs, and he ended up with enough to treat a few more of his patients here in Cange. He intends to increase those numbers, he says. He and his colleagues back in Massachusetts are working on grant proposals to obtain a larger, more reliable supply. They’ll find the money, he’s told me. “Of course we’ll find the money.”
He holds up the precious bottle for Ti Ofa to see. He shakes it, and the pills rattle around inside. He tells Ti Ofa that he’ll start treating him with this drug and two others now. They won’t eradicate HIV from his body, Farmer explains, but they will take away his symptoms and, if he’s lucky, let him live for many years as if he’d never caught the virus. He only has to promise that he’ll never miss a dose.
Ti Ofa says he won’t, but he’s still looking at his shoes. Farmer leans closer to him. “I don’t want you to be discouraged.”
Ti Ofa looks up. “Just talking to you makes me feel better. Now I know I’ll sleep tonight.” He wants to talk, and I suppose he knows he’s welcome to do so. “My situation is so bad. I keep hurting my head because I live in such a crowded house. We only have one bed, and I let my children sleep on it, so I have to sleep under the bed, and I forget, and I hit my head when I sit up. I don’t forget what you did for me, Doktè Paul. When I was sick and no one would touch me, you used to sit on my bed with your hand on my head. They had to tie up the dogs in the village, you walked around so late to see sick people.” Ti Ofa declares, “I would like to give you a chicken or a pig.”